DOCSLIB.ORG

Cellulitis: a Review of 62

Total Page：16

File Type：pdf, Size：1020Kb

Download full-text PDF Read full-text
Cellulitis: a Review of 62 Clinical Review & Education Review Cellulitis A Review Adam B. Raff, MD, PhD; Daniela Kroshinsky, MD, MPH CME Quiz at IMPORTANCE Cellulitis is an infection of the deep dermis and subcutaneous tissue, presenting jamanetworkcme.com with expanding erythema, warmth, tenderness, and swelling. Cellulitis is a common global health burden, with more than 650 000 admissions per year in the United States alone. OBSERVATIONS In the United States, an estimated 14.5 million cases annually of cellulitis account for $3.7 billion in ambulatory care costs alone. The majority of cases of cellulitis are nonculturable and therefore the causative bacteria are unknown. In the 15% of cellulitis cases in which organisms are identified, most are due to β-hemolytic Streptococcus and Staphylococcus aureus. There are no effective diagnostic modalities, and many clinical conditions appear similar. Treatment of primary and recurrent cellulitis should initially cover Streptococcus and methicillin-sensitive S aureus, with expansion for methicillin-resistant S aureus (MRSA) in cases of cellulitis associated with specific risk factors, such as athletes, children, men who have sex with men, prisoners, military recruits, residents of long-term care facilities, those with prior MRSA exposure, and intravenous drug users. Five days of treatment is sufficient with extension if symptoms are not improved. Addressing predisposing factors can minimize risk of recurrence. CONCLUSIONS AND RELEVANCE The diagnosis of cellulitis is based primarily on history and Author Affiliations: Harvard Medical physical examination. Treatment of uncomplicated cellulitis should be directed against School, Massachusetts General Streptococcus and methicillin-sensitive S aureus. Failure to improve with appropriate first-line Hospital, Boston. antibiotics should prompt consideration for resistant organisms, secondary conditions that Corresponding Author: Daniela mimic cellulitis, or underlying complicating conditions such as immunosuppression, chronic Kroshinsky, MD, MPH, liver disease, or chronic kidney disease. 50 Staniford St, #200, Boston, MA 02114 ([email protected]). Section Editors: Edward Livingston, JAMA. 2016;316(3):325-337. doi:10.1001/jama.2016.8825 MD, Deputy Editor, and Mary McGrae McDermott, MD, Senior Editor. ellulitis is a bacterial infection of the skin, presenting with otic reference tools were also reviewed. Bibliographies of the poorly demarcated erythema, edema, warmth, and ten- retrieved studies and previous reviews were searched for other rel- C derness. Although common, it often can be a diagnostic and evant studies. Initially, 595 articles were identified for full review, therapeutic challenge. In this review, the pathophysiology, micro- and of these, the most pertinent 125 were selected for inclusion. biology, clinical presentation, and risk factors of cellulitis are dis- Articles were reviewed for the quality of evidence and contribution cussed. The approach to diagnosis is reviewed and the importance to current understanding of cellulitis, with priority given for clinical of differentiating cellulitis from clinical mimics of cellulitis is high- trials, large observational studies, and more recently published lighted. An approach to empirical treatment is presented, with re- articles. cent recommendations from the literature. Results Methods Epidemiology A literature search of the entire PubMed database was conducted The majority of epidemiology studies on cellulitis rely on Interna- with search terms and synonyms for cellulitis. The search was per- tional Classification of Diseases, Ninth Revision, codes (ie, 681.x and formed on October 9, 2014, and repeated on August 28, 2015. The 682.x) that unfortunately link cellulitis and abscess, creating some initial search identified 10 154 articles and the updated search iden- limitations. However, these data remain valuable by providing a gen- tified an additional 306. Studies published in non-English lan- eral scope of the problem and trends over time. guages (unless translated), and studies involving exclusively chil- Cellulitis or abscess is a common diagnosis whose incidence is dren or animals were excluded. Meta-analyses, systematic reviews, increasing and accounted for 10% of infectious disease–related US references cited in published clinical practice guidelines, and antibi- hospitalizations from 1998 to 2006,1 with annual US ambulatory jama.com (Reprinted) JAMA July 19, 2016 Volume 316, Number 3 325 Copyright 2016 American Medical Association. All rights reserved. Downloaded From: http://jama.jamanetwork.com/ by a University Of New Mexico User on 07/27/2016 Clinical Review & Education Review Diagnosis and Treatment of Cellulitis visits (outpatient and emergency departments) increasing from 4.6 burden, resulting in a greater likelihood that they would have sys- million in 1997 to 9.6 million in 2005.2 Furthermore, a significant temic signs of infection and undergo blood culture examination than proportion of patients with cellulitis are hospitalized for manage- the typical cellulitis patient. Because most cellulitis is treated em- ment, and inpatient numbers are increasing, with the number of pirically,bacterial pathogens are rarely identified in the disease, mak- hospital stays for cellulitis or abscess in the United States increasing ing it impossible to know the true frequency of bacterial etiologies. by 73%, from 12 per 10 000 in 1997 to 21 per 10 000 in 2011.3 In There has been increasing concern about antibiotic-resistant addition, a Netherlands study demonstrated that the total number bacteria, such as community-acquired methicillin-resistant S aureus of erysipelas, cellulitis, or abscess hospitalizations per inhabitants (MRSA), which is reflected in the increased use of anti-MRSA anti- per year increased markedly with age, with a 5-fold increase from biotics (eg, vancomycin, trimethoprim-sulfamethoxazole, doxycy- patients aged 54 years to those aged 85 years or older (incidence cline, clindamycin) and broad-spectrum gram-negative antibiotics >100 per 100 000).4 (eg, β-lactam/β-lactamase inhibitors, levofloxacin, ceftriaxone) during the past decade.40 However, most cases of cellulitis do not Pathophysiology involve gram-negative organisms, and in cases of nonpurulent Cellulitis is a deep dermal and subcutaneous infection that occurs and uncomplicated cellulitis, the addition of antibiotics against when pathogens gain entry into the dermis through breaks in the community-acquired MRSA did not improve outcomes.41 As such, skin. Cutaneous barrier disruption can be caused by toe web space narrow-spectrum antibiotics against Streptococcus and methicillin- bacteria, fungal foot infections (eg, tinea pedis, onychomycosis), sensitive S aureus remain appropriate. In purulent cellulitis (pres- pressure ulcers, and venous leg ulcers. Skin surface pathogenic or- ence of a pustule, abscess, or purulent drainage), S aureus infection ganism colonization is reduced by the presence of a low surface pH, is more likely, as demonstrated by a study of 422 patients who pre- low temperature, and commensal microorganisms. sented with “purulent skin and soft tissue infections” to 11 emer- The histologic features of cellulitis are nonspecific and include gency departments throughout the United States, in which dermal edema, lymphatic dilation, and diffuse, heavy neutrophil in- skin surface swab cultures revealed MRSA in 59% of patients, filtration around blood vessels. Later stages may also feature lym- methicillin-sensitive S aureus in 17%, and β-hemolytic streptococci phocytes and histiocytes, along with granulation tissue. in 2.6%.42 Because methicillin-sensitive S aureus and MRSA can be Usually, cultures performed with needle aspiration or biopsy difficult to differentiate according to clinical features alone,43 yield negative results, and when they are positive, the concentra- MRSA should be considered for purulent infections in known high- tion of bacteria is low.5,6 This suggests that either a very small num- risk populations, such as athletes, children, men who have sex with ber of bacteria are responsible for the induction of the robust in- men, prisoners, military recruits, residents of long-term care facili- flammatory response or the immune system reduces the number ties, individuals with previous MRSA exposure, and intravenous of viable bacteria to very low or nonexistent numbers by the time drug users.44 patients present for treatment. Bacterial toxins and other inflam- matory mediators that trigger an escalating inflammatory re- Clinical Presentation sponse may better define the pathogenesis of cellulitis than the bac- Cellulitis usually presents as an acute, spreading, poorly demar- terial load itself. cated area of erythema. The skin findings in cellulitis follow the clas- sic signs of inflammation: dolor (pain), calor (heat), rubor (erythema), Microbiology and tumor (swelling). Additional clinical features may include di- Cellulitis in immunocompetent adults is usually thought to be caused lated and edematous skin lymphatics, leading to a peau d’orange by group A streptococci (Streptococcus pyogenes), with Staphylo- (orange peel) appearance; bulla formation; or inflamed lymphatics coccus aureus as a notable but less common cause.7 However, given proximal to the area of cellulitis, leading to linear erythematous the difficulty culturing cellulitis, the specific causative bacterium in streaks or lymphangitis (Figure 1). Inflammation in the lymphatics most cases remains unknown, and several studies demonstrate
Load more

Recommended publications
  • Cutaneous Manifestations of HIV Infection Carrie L
    Chapter Title Cutaneous Manifestations of HIV Infection Carrie L. Kovarik, MD Addy Kekitiinwa, MB, ChB Heidi Schwarzwald, MD, MPH Objectives Table 1. Cutaneous manifestations of HIV 1. Review the most common cutaneous Cause Manifestations manifestations of human immunodeficiency Neoplasia Kaposi sarcoma virus (HIV) infection. Lymphoma 2. Describe the methods of diagnosis and treatment Squamous cell carcinoma for each cutaneous disease. Infectious Herpes zoster Herpes simplex virus infections Superficial fungal infections Key Points Angular cheilitis 1. Cutaneous lesions are often the first Chancroid manifestation of HIV noted by patients and Cryptococcus Histoplasmosis health professionals. Human papillomavirus (verruca vulgaris, 2. Cutaneous lesions occur frequently in both adults verruca plana, condyloma) and children infected with HIV. Impetigo 3. Diagnosis of several mucocutaneous diseases Lymphogranuloma venereum in the setting of HIV will allow appropriate Molluscum contagiosum treatment and prevention of complications. Syphilis Furunculosis 4. Prompt diagnosis and treatment of cutaneous Folliculitis manifestations can prevent complications and Pyomyositis improve quality of life for HIV-infected persons. Other Pruritic papular eruption Seborrheic dermatitis Overview Drug eruption Vasculitis Many people with human immunodeficiency virus Psoriasis (HIV) infection develop cutaneous lesions. The risk of Hyperpigmentation developing cutaneous manifestations increases with Photodermatitis disease progression. As immunosuppression increases, Atopic Dermatitis patients may develop multiple skin diseases at once, Hair changes atypical-appearing skin lesions, or diseases that are refractory to standard treatment. Skin conditions that have been associated with HIV infection are listed in Clinical staging is useful in the initial assessment of a Table 1. patient, at the time the patient enters into long-term HIV care, and for monitoring a patient’s disease progression.
    [Show full text]
  • Cutaneous Manifestations of Newborns in Omdurman Maternity Hospital
    ﺑﺴﻢ اﷲ اﻟﺮﺣﻤﻦ اﻟﺮﺣﻴﻢ Cutaneous Manifestations of Newborns in Omdurman Maternity Hospital A thesis submitted in the partial fulfillment of the degree of clinical MD in pediatrics and child health University of Khartoum By DR. AMNA ABDEL KHALIG MOHAMED ATTAR MBBS University of Khartoum Supervisor PROF. SALAH AHMED IBRAHIM MD, FRCP, FRCPCH Department of Pediatrics and Child Health University of Khartoum University of Khartoum The Graduate College Medical and Health Studies Board 2008 Dedication I dedicate my study to the Department of Pediatrics University of Khartoum hoping to be a true addition to neonatal care practice in Sudan. i Acknowledgment I would like to express my gratitude to my supervisor Prof. Salah Ahmed Ibrahim, Professor of Peadiatric and Child Health, who encouraged me throughout the study and provided me with advice and support. I am also grateful to Dr. Osman Suleiman Al-Khalifa, the Dermatologist for his support at the start of the study. Special thanks to the staff at Omdurman Maternity Hospital for their support. I am also grateful to all mothers and newborns without their participation and cooperation this study could not be possible. Love and appreciation to my family for their support, drive and kindness. ii Table of contents Dedication i Acknowledgement ii Table of contents iii English Abstract vii Arabic abstract ix List of abbreviations xi List of tables xiii List of figures xiv Chapter One: Introduction & Literature Review 1.1 The skin of NB 1 1.2 Traumatic lesions 5 1.3 Desquamation 8 1.4 Lanugo hair 9 1.5
    [Show full text]
  • Cellulitis (You Say, Sell-You-Ly-Tis)
    Cellulitis (you say, sell-you-ly-tis) Any area of skin can become infected with cellulitis if the skin is broken, for example from a sore, insect bite, boil, rash, cut, burn or graze. Cellulitis can also infect the flesh under the skin if it is damaged or bruised or if there is poor circulation. Signs your child has cellulitis: The skin will look red, and feel warm and painful to touch. There may be pus or fluid leaking from the skin. The skin may start swelling. The red area keeps growing. Gently mark the edge of the infected red area How is with a pen to see if the red area grows bigger. cellulitis spread? Red lines may appear in the skin spreading out from the centre of the infection. Bad bacteria (germs) gets into broken skin such as a cut or insect bite. What to do Wash your hands before and Cellulitis is a serious infection that needs to after touching the infected area. be treated with antibiotics. Keep your child’s nails short and Go to the doctor if the infected area is clean. painful or bigger than a 10 cent piece. Don’t let your child share Go to the doctor immediately if cellulitis is bath water, towels, sheets and near an eye as this can be very serious. clothes. Make sure your child takes the antibiotics Make sure your child rests every day until they are finished, even if and eats plenty of fruit and the infection seems to have cleared up. The vegetables and drinks plenty of antibiotics need to keep killing the infection water.
    [Show full text]
  • STD Glossary of Terms
    STD 101 In A Box- STD Glossary of Terms Abstinence Not having sexual intercourse Acquired A disease of the human immune system caused by the Human Immunodeficiency Virus (HIV). HIV/AIDS represents the entire range of Immunodeficiency disease caused by the HIV virus from early infection to late stage Syndrome (AIDS) symptoms. Anal Intercourse Sexual contact in which the penis enters the anus. Antibiotic A medication that either kills or inhibits the growth of a bacteria. Antiviral A medication that either kills or inhibits the growth of a virus. A thinning of tissue modified by the location. In epidermal atrophy, the epidermis becomes transparent with a loss of skin texture and cigarette Atrophic paper-like wrinkling. In dermal atrophy, there is a loss of connective tissue and the lesion is depressed. A polymicrobial clinical syndrome resulting from replacement of the Bacterial Vaginosis normal hydrogen peroxide producing Lactobacillus sp. in the vagina with (BV) high concentrations of anaerobic bacteria. The common symptom of BV is abnormal homogeneous, off-white, fishy smelling vaginal discharge. Cervical Motion A sign found on pelvic examination suggestive of pelvic pathology; when Tenderness (CMT) movement of the cervix during the bimanual exam elicits pain. The lower, cylindrical end of the uterus that forms a narrow canal Cervix connecting the upper (uterus) and lower (vagina) parts of a woman's reproductive tract. The most common sexually transmitted bacterial infection in the U.S., caused by the bacteria Chlamydia trachomatis. Often no symptoms are present, especially in women. Untreated chlamydia can cause sterility, Chlamydia Pelvic Inflammatory Disease (PID), and increase the chances for life- threatening tubal pregnancies.
    [Show full text]
  • Survey of Skin Disorders in Newborns: Clinical Observation in an Egyptian Medical Centre Nursery A.A
    املجلة الصحية لرشق املتوسط املجلد الثامن عرش العدد اﻷول Survey of skin disorders in newborns: clinical observation in an Egyptian medical centre nursery A.A. El-Moneim 1 and R.E. El-Dawela 2 مسح لﻻضطرابات اجللدية لدى الولدان: مﻻحظة رسيرية يف حضانة يف مركز طبي يف مرص عبري أمحد عبد املنعم، رهيام عز الدولة الرشقاوي اخلﻻصة:مل َ ْت َظ اﻻضطرابات اجللدية لدى الولدان بدراسات جيدة يف مرص. وقد هدفت الباحثتان إىل دراسة أنامط التغريات اجللدية يف عينة من ِ الولدان املرصيني، وهي دراسة وصفية استباقية أترابية شملت ستة مئة وليد يف َّحضانة يف مستشفى جامعة سوهاج، َّوتضمنت الفحص اجللدي خﻻل اﻷيام اخلمسة اﻷوىل بعد الوﻻدة. وقد تم كشف اﻻضطرابات اجللدية لدى 240 ًوليدا )40%( ولوحظت الومحات لدى 100 وليد )%16.7(، ومعظمها من النمط ذي اخلﻻيا امليﻻنية )لطخات منغولية لدى 11.7% مع ومحات وﻻدية ذات ميﻻنية اخلﻻيا لدى 2.7%(. كام ُك ِش َف ْت العداوى الفطرية اجللدية، ومنها داء َّاملبيضات الفموية، وعدوى الفطريات يف مناطق احلفاظات أو َالـم َذح الناجم عن عدوى َّاملبيضات يف اﻷرفاغ )أصل الفخذ(، وذلك لدى 13.3%، ُوكشفت بعض العداوى اجلرثومية يف 1.3%من الولدان. وتشري املقارنات مع الدراسات اﻷخرى يف أرجاء العامل إىل معدل مرتفع للعدوى بالفطريات مع معدل منخفض للومحات الوﻻدية يف دراستنا للولدان، وتويص الباحثتان بإجراء تقييم روتيني جلدي للولدان، ّوﻻسيام يف ضوء املعدﻻت املرتفعة للعدوى اجللدية بالفطريات. ABSTRACT The frequency of neonatal skin disorders has not been well studied in Egypt. Our aim was to address patterns of dermatological changes in a sample of Egyptian newborns. In a descriptive prospective cohort study 600 newborns in Sohag University hospital nursery were dermatologically examined within the first 5 days of birth.
    [Show full text]
  • Skin Disease and Disorders
    Sports Dermatology Robert Kiningham, MD, FACSM Department of Family Medicine University of Michigan Health System Disclosures/Conflicts of Interest ◼ None Goals and Objectives ◼ Review skin infections common in athletes ◼ Establish a logical treatment approach to skin infections ◼ Discuss ways to decrease the risk of athlete’s acquiring and spreading skin infections ◼ Discuss disqualification and return-to-play criteria for athletes with skin infections ◼ Recognize and treat non-infectious skin conditions in athletes Skin Infections in Athletes ◼ Bacterial ◼ Herpetic ◼ Fungal Skin Infections in Athletes ◼ Very common – most common cause of practice-loss time in wrestlers ◼ Athletes are susceptible because: – Prone to skin breakdown (abrasions, cuts) – Warm, moist environment – Close contacts Cases 1 -3 ◼ 21 year old male football player with 4 day h/o left axillary pain and tenderness. Two days ago he noticed a tender “bump” that is getting bigger and more tender. ◼ 16 year old football player with 3 day h/o mildly tender lesions on chin. Started as a single lesion, but now has “spread”. Over the past day the lesions have developed a dark yellowish crust. ◼ 19 year old wrestler with a 3 day h/o lesions on right side of face. Noticed “tingling” 4 days ago, small fluid filled lesions then appeared that have now started to crust over. Skin Infections Bacterial Skin Infections ◼ Cellulitis ◼ Erysipelas ◼ Impetigo ◼ Furunculosis ◼ Folliculitis ◼ Paronychea Cellulitis Cellulitis ◼ Diffuse infection of connective tissue with severe inflammation of dermal and subcutaneous layers of the skin – Triad of erythema, edema, and warmth in the absence of underlying foci ◼ S. aureus or S. pyogenes Erysipelas Erysipelas ◼ Superficial infection of the dermis ◼ Distinguished from cellulitis by the intracutaneous edema that produces palpable margins of the skin.
    [Show full text]
  • Final Report of the Lyme Disease Review Panel of the Infectious Diseases Society of America (IDSA)
    Final Report of the Lyme Disease Review Panel of the Infectious Diseases Society of America (IDSA) INTRODUCTION AND PURPOSE In November 2006, the Connecticut Attorney General (CAG), Richard Blumenthal, initiated an antitrust investigation to determine whether the Infectious Diseases Society of America (IDSA) violated antitrust laws in the promulgation of the IDSA’s 2006 Lyme disease guidelines, entitled “The Clinical Assessment, Treatment, and Prevention of Lyme Disease, Human Granulocytic Anaplasmosis, and Babesiosis: Clinical Practice Guidelines by the Infectious Diseases Society of America” (the 2006 Lyme Guidelines). IDSA maintained that it had developed the 2006 Lyme disease guidelines based on a proper review of the medical/scientifi c studies and evidence by a panel of experts in the prevention, diagnosis, and treatment of Lyme disease. In April 2008, the CAG and the IDSA reached an agreement to end the investigation. Under the Agreement and its attached Action Plan, the 2006 Lyme Guidelines remain in effect, and the Society agreed to convene a Review Panel whose task would be to determine whether or not the 2006 Lyme Guidelines were based on sound medical/scientifi c evidence and whether or not these guidelines required change or revision. The Review Panel was not charged with updating or rewriting the 2006 Lyme Guidelines. Any recommendation for update or revision to the 2006 Lyme Guidelines would be conducted by a separate IDSA group. This document is the Final Report of the Review Panel. REVIEW PANEL MEMBERS Carol J. Baker, MD, Review Panel Chair Baylor College of Medicine Houston, TX William A. Charini, MD Lawrence General Hospital, Lawrence, MA Paul H.
    [Show full text]
  • Sepsis and Septic Shock: Endothelial Molecular Pathogenesis Associated with Vascular Microthrombotic Disease Jae C
    Chang Thrombosis Journal (2019) 17:10 https://doi.org/10.1186/s12959-019-0198-4 REVIEW Open Access Sepsis and septic shock: endothelial molecular pathogenesis associated with vascular microthrombotic disease Jae C. Chang Abstract In addition to protective “immune response”, sepsis is characterized by destructive “endothelial response” of the host, leading to endotheliopathy and its molecular dysfunction. Complement activation generates membrane attack complex (MAC). MAC causes channel formation to the cell membrane of pathogen, leading to death of microorganisms. In the host, MAC also may induce channel formation to innocent bystander endothelial cells (ECs) and ECs cannot be protected. This provokes endotheliopathy, which activates two independent molecular pathways: inflammatory and microthrombotic. Activated inflammatory pathway promotes the release of inflammatory cytokines and triggers inflammation. Activated microthrombotic pathway mediates platelet activation and exocytosis of unusually large von Willebrand factor multimers (ULVWF) from ECs and initiates microthrombogenesis. Excessively released ULVWF become anchored to ECs as long elongated strings and recruit activated platelets to assemble platelet-ULVWF complexes and form “microthrombi”. These microthrombi strings trigger disseminated intravascular microthrombosis (DIT), which is the underlying pathology of endotheliopathy- associated vascular microthrombotic disease (EA-VMTD). Sepsis-induced endotheliopathy promotes inflammation and DIT. Inflammation produces inflammatory response
    [Show full text]
  • Non-Dermatomal Varicella-Zoster Skin Infection: Disseminated Cutaneous Herpes Zoster Without Dermatome in an Immunosuppressed Woman
    Volume 23 Number 10 | October 2017 Dermatology Online Journal || Case Report DOJ 23 (10): 4 Non-dermatomal varicella-zoster skin infection: disseminated cutaneous herpes zoster without dermatome in an immunosuppressed woman Lindsay P Osborn1 BA,, Philip R Cohen2 MD Affiliations: 1Medical College of Georgia, Augusta, Georgia, 2University of California, San Diego, California Corresponding Author: Lindsay P. Osborn, 1 Seventh Street, Suite 1403, Augusta, GA 30901, Email: [email protected] Introduction Abstract Herpes viral infection in humans includes both Disseminated herpes zoster is defined as the presence herpes simplex (HSV) and herpes zoster. The varicella of more than 20 lesions outside the dermatome. zoster virus (VZV) is the etiology of both primary This unusual presentation is more common in varicella and herpes zoster (commonly known as immunosuppressed patients. Complications such chicken pox and shingles, respectively), with herpes as hepatitis, encephalitis, and pneumonitis are more zoster being the re-activated form of the virus. The likely in individuals with disseminated varicella zoster classical presentation of herpes zoster is a unilateral virus infection. distribution of vesicles along a single or adjacent dermatome [1]. Disseminated herpes zoster is A 63-year-old woman being treated for breast cancer defined as having more than 20 lesions outside the developed multiple pustules and vesicles days primary or adjacent dermatome [2]. after starting doxorubicin and cyclophosphamide chemotherapy. Ten individual lesions appeared on Although uncommon among all herpes zoster her chest, abdomen, back, and leg. Non-dermatomal infections, the prevalence of disseminated VZV in disseminated herpes zoster was suspected. She was a setting of immunosuppression is thought to be treated with oral antiviral therapy, as well as with oral anywhere from 10 to 40% [3, 4].
    [Show full text]
  • Perianal Streptococcal Infection Kumara V
    CASE REPORT Perianal Streptococcal Infection Kumara V. Nibhanipudi, MD A 3-year-old boy is brought to the ED for evaluation of perianal desquamation. Case The mother of a 3-year-old boy presented her son to the ED for evaluation after she noticed peeling of the skin in his perianal region. She stated that the peeling had started 1 day prior to presentation. Two days earlier, the mother had brought the same patient to the ED for evaluation of a fever, sore throat, and a slight rash over his face. The boy’s vital signs at the initial presentation were: temperature, 101.8°F; heart rate, 102 beats/minute; and respira- tory rate, 28 breaths/minute. Oxygen satu- ration was 98% on room air. During this first visit, the mother denied the child having had any fever, chills, headache, sore throat, facial rash, joint pain, or pain on defecation. He had no significant medical history and no known drug allergies. After examination, a throat culture was taken, and the patient was giv- en acetaminophen and discharged home with a diagnosis of viral syndrome. At the second presentation, physical examination revealed a well-developed child in no distress. The examination was negative except for a 4 x 2 cm area of des- quamation present over the perianal region (Figure). The area of desquamation was dry, mild- Figure. Photograph of the patient’s perianal region showing the area of desquamation. ly erythematous without discharge, and Dr Nibhanipudi is a professor of clinical emergency medicine at New York Medical College - Metropolitan Hospital Center, New York.
    [Show full text]
  • Facial Impetigo and Preseptal Cellulitis Associated with Job's Syndrome, A
    Facial impetigo and preseptal cellulitis associated with Job’s Syndrome, a rare hyperimmunoglobinemia E syndrome (HIES) C Tong, OD; R Frick, OD, FAAO; D Hitchmoth, OD, FAAO This case discusses the diagnosis and management of severe preseptal cellulitis caused by Job’s Syndrome. This disease compromises several body systems, especially the immune system, and causes recurrent infections. I. Case History -67 year-old white male presents from the emergency department with marked erythema, edema and crusted lesions of both eyelids OD and face for 2 days -Medical history: Job’s Syndrome, hyperlipidemia and Neurofibromatosis Type 1 -Medications: Enoxaparin, Ibuprofen, and Simvastatin. II. Pertinent findings -Best corrected vision: R 20/25 and L 20/30 -Marked honey-colored, encrusted, exudative lesions on upper and lower lids OD, left forehead, and extremities with OD swollen shut -Flat and raised, coffee colored lesions along extremities and trunk -No fever, lymphadenopathy or other systemic complaints -Pupils normal with no afferent defect -No proptosis -Extraocular muscles intact with no diplopia and no pain/paresthesia along cranial nerve V -Anterior and posterior segment unremarkable except iris lisch nodules OU -Computed tomography (CT) with contrast of the orbits found preseptal soft tissue changes [cellulitis] and normal post-septal space without other orbital abnormalities. III. Differential Diagnoses - Preseptal Cellulitis, Herpes Zoster Ophthalmicus, orbital cellulitis, insect bite, hordeola, infectious dermatitis, allergic dermatitis, orbital lymphoma, orbital neurofibroma, Pott’s puffy tumor and other sinus infection IV. Diagnosis and Discussion - Job’s Syndrome, or HIES, is a rare, inherited disease marked by high levels of immunoglobulin E (IgE), an antibody that triggers immune responses against parasites, infections and noninfectious allergens -Patients with HIES often have multi-system ailments involving skin, bones, or lungs and present with recurrent, dramatic skin infections -The exudative skin lesions were classic for impetigo ecthyma.
    [Show full text]
  • Bacterial Skin and Soft Tissue Infections
    VOLUME 39 : NUMBER 5 : OCTOBER 2016 ARTICLE Bacterial skin and soft tissue infections Vichitra Sukumaran SUMMARY Advanced trainee1 Sanjaya Senanayake Bacterial skin infections are common presentations to both general practice and the Senior specialist1 emergency department. Associate professor of 2 The optimal treatment for purulent infections such as boils and carbuncles is incision and medicine drainage. Antibiotic therapy is not usually required. 1 Infectious Diseases Most uncomplicated bacterial skin infections that require antibiotics need 5–10 days of treatment. Canberra Hospital 2 Australian National There is a high prevalence of purulent skin infections caused by community-acquired University Medical School (non‑multiresistant) methicillin-resistant Staphylococcus aureus. It is therefore important to Canberra provide adequate antimicrobial coverage for these infections in empiric antibiotic regimens. Keywords antibiotics, cellulitis, Introduction Cellulitis and erysipelas impetigo, soft tissue It is important to have a good understanding of Both cellulitis and erysipelas manifest as spreading infection the common clinical manifestations and pathogens areas of skin erythema and warmth. Localised involved in bacterial skin infections to be able to infections are often accompanied by lymphangitis and Aust Prescr 2016;39:159–63 manage them appropriately. The type of skin infection lymphadenopathy. Not infrequently, groin pain and http://dx.doi.org/10.18773/ depends on the depth and the skin compartment tenderness due to inguinal lymphadenitis will precede austprescr.2016.058 involved. The classification and management of these the cellulitis. Some patients can be quite unwell with infections are outlined in Table 1. fevers and features of systemic toxicity. Bacteraemia, although uncommon (less than 5%), still occurs. Impetigo Erysipelas involves the upper dermis and superficial Impetigo is a superficial bacterial infection that can lymphatics.
    [Show full text]